Angel Silmi Moyano

Long-term outcomes after robotic sacrocolpopexy in pelvic organ prolapse: prospective analysis.

OBJECTIVE To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. METHODS We conducted a prospective analysis of our series of robotic sacrocolpopexy. INCLUSION CRITERIA patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. RESULTS 31 consecutive procedures were included. Mean patient age was 65.2 (50-81) years. Mean operating room time was 186 (150-230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16-33) months. CONCLUSIONS Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up.Objective: To evaluate the feasibility and long-term outcomes of our initial series of robot-assisted laparoscopic sacrocolpopexy. Methods: We conducted a prospective analysis of our series of robotic sacrocolpopexy. Inclusion criteria: patients with grades III and IV cystocele and or other symptomatic pelvic organ prolapse. We performed a transperitoneal four-trocar technique with the Da Vinci robotic system using two polypropylene meshes for fixation to the sacral promontory. The primary outcome was recurrence; secondary outcomes included operating room time, blood loss, conversion to open surgery, complications and length of stay. Results: 31 consecutive procedures were included. Mean patient age was 65.2 (50–81) years. Mean operating room time was 186 (150–230) min. We converted 1 case to laparoscopy (3.2%). There were two major complications (1 acute myocardial infarction and 1 reoperation for excess tension with syncopes), two minor complications (1 wound infection and 1 ileus) and no recurrences at a mean follow-up of 24.5 (16–33) months. Conclusions: Robotic sacrocolpopexy could possibly improve with experience after overcoming the learning curve. There is no doubt it is a reproducible technique, but its safety and efficacy still need to be proven. Our initial series demonstrated good outcomes and no recurrences at 24.5 months of follow-up.

Prevalencia de síntomas del tracto urinario inferior relacionados con la hiperplasia benigna de próstata. Estudio de 1804 hombres de 40 años o más residentes en Madrid durante 1999-2000

Resumen Introduccion Los sintomas del tracto urinario inferior (STUI) asociados con la hiperplasia benigna de prostata estan presentes en el 20-30% de la poblacion espanola masculina de 50 anos o mas. El objetivo de este estudio es analizar las caracteristicas clinicas y epidemiologicas de los pacientes con STUI. Material y metodos Estudio transversal realizado entre los anos 1999 y 2000 en 1804 hombres de 40 anos o mas residentes en Madrid. Mediante entrevista telefonica se recabo informacion sociodemografica de los participantes y se evaluo la presencia de STUI mediante el I-PSS (International Prostate Symptoms Score). La asociacion entre variables cualitativas se evaluo con el test ?2 o el exacto de Fisher. Se ajusto un modelo de regresion logistica para evaluar la probabilidad de tener STUI moderados/severos controlando la confusion. Resultados La prevalencia de STUI moderados/severos fue del 16,6% (IC95%: 14,8-18,3). Cerca del 90% de los participantes consumian aceite de oliva, el 71,5% alcohol, el 63,1% no fumaba y el 96,9% no consumian drogas. Un 27,7% referia hipertension y un 8,8% diabetes. Los hombres de 70 anos o mas tenian una frecuencia de STUI moderados/severos tres veces mayor que los hombres mas jovenes (OR: 3,31; IC95%: 2,10-5,22). El nivel bajo de estudios, frente al alto, mostro una frecuencia 2,2 veces mayor de STUI moderados/severos (IC95%: 1,42-3,46), asi como el consumo de aceite de semillas, frente al de oliva (OR: 1,86; IC95%: 0,98-3,55). Conclusiones La historia familiar de enfermedades urologicas, la edad, el nivel bajo de estudios, la hipertension, la diabetes y el consumo de aceite de semillas se asociaron de forma independiente con la presencia de STUI mas severos, mientras el consumo moderado de alcohol y tabaco se asocio de forma independiente a la presencia de STUI leves

Desarrollo y validación del primer cuestionario español de calidad de vida en pacientes con cáncer de próstata, basado en la percepción del paciente

Development and validation of the first spanish questionnaire of quality of life in patients with prostate cancer, based on the patients perception Abstract Background: To ensure health related quality of life (HRQOL) during the survival of patients with prostate cancer (PCa) is a priority. The development of specific HRQOL questionnaires aids to assess the disease impact, its treatment and the patients perception (concerns, expectations and interests) that might go unnoticed. Objectives : To develop and validate the first Spanish HRQL questionnaire specific for patients with PCa. Materials and methods: The questionnaire CAVIPRES had 3 phases of development:1.-generation of items (literature rese - arch,expertmeetingand2focusgroupswithpatients),2.-reductionofitems(self-administeredsurveywithapreliminaryver - sion and clinimetric and psychometric analyses), 3: validation of the questionnaire (observational study with 2 visits where patients completed the CAVIPRES, SF-36 and UCLA-PCI tests and analysis of psychometric properties in terms of validity, reliability and sensitivity to change). Results: A preliminary list of 75 potential items was obtained in phase 1.412 patients were recruited and answered this pre - liminary version in phase 2. 35 items were deleted. 436 patients responded to the definitive-30-items obtained version (CAVI - PRES-30) in Phase 3. CAVIPRES-30 showed feasibility (items lost <4%, ceiling effect: 0% floor effect: 0% in the overall score), high reliability in terms of internal consistency (alpha = 0.77) and re-test reliability (ICC = 0.92). There was a good correlation between tests CAVIPRES and SGF-36 and UCLA-PCI for similar domains Conclusion: ThequestionnaireCAVIPRES-30isafeasible,reliableandsensitivetochange,usefulinclinicalresearchforpros - tate cancer.

Colposacropexia laparoscópica asistida por robot como tratamiento del prolapso urogenital

Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.Laparoscopic colposacropexy has become a substitute for open surgery in the treatment of pelvic organ prolapse. In the same way, robotic assisted surgery is a new step in the evolution of the procedure. In this paper we intend to show our surgical technique and preliminary results. From November 2006 to date, 10 patients have undergone this procedure at the Hospital Clinico San Carlos. The main indication for the operation was existence of symptomatic pelvic prolapse. Both patients with or without hysterectomy have been operated, without making significant differences between them. Preoperative evaluation workout included: cystogram, urinary tract ultrasound and urodynamics in all cases; urinary tract MRI was performed only in selected cases. All patients underwent surgery under general anesthesia, with at least three robotic trocars (8 mm) and one conventional trocar for the assistant; 2 accessory trocars were necessary in some cases, mainly at the beginning of the series. Most procedures in our series were associated with a transobturator suburethral sling for the treatment of stress urinary incontinence or prevention of its appearance after prolapse repair. Our results are comparable to those reported in other larger series in terms of operative time, hospital stay and early or late complications. Pending an evaluation on the long term with larger series, we can include robot assisted colposacropexy among the therapeutic options for symptomatic pelvic floor prolapse repair.OBJETIVOS La colposacropexia laparoscopica es una tecnica que ha venido a sustituir a la cirugia abierta para el tratamiento de los prolapsos del suelo pelvico. De la misma manera, la cirugia asistida por robot supone un nuevo paso en la evolucion de la tecnica. En este articulo pretendemos mostrar, tanto nuestra tecnica quirurgica como los resultados preliminares obtenidos con la misma. En el Hospital Clinico San Carlos han sido intervenidas con esta tecnica un total de 10 pacientes, desde Noviembre de 2006 hasta la fecha. La principal indicacion en nuestro caso ha sido la presencia de prolapsos pelvicos sintomaticos, habiendose intervenido tanto pacientes histerectomizadas como no histerectomizadas, sin poder establecer diferencias significativas entre ambos casos. Como estudio preoperatorio se ha incluido: Cistografia, Ecografia Reno-vesical, Estudio Urodinamico en todos los casos, y tan solo en aquellos en los que se ha considerado oportuno una Uro-Resonancia. Todas las pacientes han sido intervenidas bajo anestesia general, mediante colocacion de un minimo de tres trocares roboticos (8mm) y uno convencional para el ayudante, aunque en algunos casos, sobretodo al inicio de la serie se precisaron 2 trocares accesorios. Asi mismo, en nuestra serie en la mayoria de los casos se ha asociado una tecnica anti-incontinencia tipo sling suburetral transobturatriz, bien para tratamiento de la incontinencia urinaria de esfuerzo (IUE), bien para prevenir su posible aparicion tras la correcion del prolapso. Los resultados obtenidos son comparables a los descritos en otras series mas numerosas en cuanto a duracion, estancia hospitalaria y complicaciones tanto precoces como tardias. A expensas de realizar una valoracion a largo plazo y con series mas amplias, podemos incluir la colposacropexia laparoscopica asistida por robot entre el arsenal terapeutico disenado para la reparacion de los prolapsos del suelo pelvico sintomaticos.

Surgical Repair and Analysis of Penile Fracture Complications

BACKGROUND The objective of this study is to describe and analyze the experience over a period of 10 years at our center through a retrospective study of a series of diagnosed and treated cases of penile fracture. MATERIAL AND METHODS From 2005 to 2009 the Urology Department of the Hospital Clínico San Carlos of Madrid carried out a retrospective case study of a total of 15 cases of penile fracture. The diagnosis was reached through physical exploration of the patient aided by a penile ultrasound; the immediate treatment performed on the patients was emergency surgical repair. RESULTS From the total in the series (n = 15), only 1 case was associated with a complete urethral fracture (6.6%). Surgical repair was performed in all cases; the average hospital stay was 2.6 days (range 1-5), and the most frequent long-term complication was erectile dysfunction in 3 of 15 cases (20%). CONCLUSIONS A penis fracture diagnosis is mostly clinical; complementary tests, such as ultrasound, are helpful but not definitive. Surgical treatment consists of an incision that allows adequate exposure of the corpora cavernosa and urethra to repair the suspected lesions found upon diagnosis. Ambulatory follow-up is essential to diagnose and treat possible complications.Background: The objective of this study is to describe and analyze the experience over a period of 10 years at our center through a retrospective study of a series of diagnosed and treated cases of penile fracture. Material and Methods: From 2005 to 2009 the Urology Department of the Hospital Clinico San Carlos of Madrid carried out a retrospective case study of a total of 15 cases of penile fracture. The diagnosis was reached through physical exploration of the patient aided by a penile ultrasound; the immediate treatment performed on the patients was emergency surgical repair. Results: From the total in the series (n = 15), only 1 case was associated with a complete urethral fracture (6.6%). Surgical repair was performed in all cases; the average hospital stay was 2.6 days (range 1–5), and the most frequent long-term complication was erectile dysfunction in 3 of 15 cases (20%). Conclusions: A penis fracture diagnosis is mostly clinical; complementary tests, such as ultrasound, are helpful but not definitive. Surgical treatment consists of an incision that allows adequate exposure of the corpora cavernosa and urethra to repair the suspected lesions found upon diagnosis. Ambulatory follow-up is essential to diagnose and treat possible complications.

La urodinámica del divertículo vesical en el varón adulto

OBJECTIVES: To evaluate the clinical and urodynamic characteristics of a series of adult males with BPH and bladder diverticula, and to analyze the changes in urodynamics in patients undergoing lower urinary tract surgery to relieve obstruction, with or without associated diverticulectomy. METHODS: We studied 91 patients in two groups: Group 1- BPH: 67 cases (73.6%) and Group 2-BPH + diverticulum: 24 cases (25%). Mean age was 65.04 years. All patients underwent urological physical examination and complete urodynamic study including cystogram. In addition, we studied 19 patients with BPH and bladder diverticula (mean age 64.58 years) who underwent either endoscopic surgery (1 I cases; 57.9%) or endoscopic surgery plus diverticulectomy (8 cases, 42. 1%). Complete clinical study and urodynamics (including cystogram) were performed preoperative and three months after surgery. Statistical significance was established at 0.05. RESULTS: Comparative study between group 1 (BPH) and group 2 (BPH with diverticulum): there were significant differences in clinical data: acute urinary retention (6.1% vs. 25%;p<0.01), and urinary tract infection (3.1% vs. 21.7%;p=0,004). All evaluated cases had single diverticula (8 cases). Urodynamic studies showed: 1) Post-void residual after free flowmetry: 45.9 ml vs. 221.4 ml, p = 0.008. 2) Bladder capacity on cystometrogram: 211.2 ml vs. 350.8 ml, p = 0.024. 3) Voiding pressure/flow study: a) Voiding with abdominal press 23.9% vs. 50%, p = 0.02. b) URA 36.5 cm H2O vs. 48.5 cm H2O, p= 0.04, c) post void residual 70.7ml vs. 210.3 ml, p= 0.004. d) Bladder contractility measurements (Wmax- isometric contractility- and W80, W20- isotonic contractility) did not show significant differences between groups. Bladder contractility duration was significantly decreased in group 2. In the analysis of patients undergoing surgery to relieve obstruction (Group A- Surgery without diverticulectomy; Group B Surgery with diverticulectomy) there were not differences between groups in clinical data. Urethral resistance parameters (URA) decreased in both groups. Group A: from 43 cm H20 to 26.3 cm H2O. Group B: from 60.6 cm H2O to 48 cm H2O. This decrease was similar after either TURP or myocapsulotomy. Post void residual diminished in both groups. There were no statistical differences between groups in Wmax, W 80-20, or volume, number and site of the diverticula. On the contrary, bladder contractility duration diminished after diverticulectomy. CONCLUSIONS: Bladder diverticula appear in the cases with highest ureteral resistance values (lower urinary tract obstruction). Standard bladder contractility parameters were not diminished. Duration of detrusor contraction was the only contractility parameter significantly affected in cases of bladder diverticula and presented a significant association with the use of abdominal press while voiding. Diverticulectomy showed an improvement of bladder contractility with longer detrusor contraction duration, which supports its use in cases of BPH-associated diverticula. Both TURP and transurethral incision of the prostate diminished urethral resistance in a similar way, so that they may be considered alternative options. Our data should be confirmed with a bigger sample size.

Key Areas in the Learning Curve for Robotic Urological Surgery: A Spanish Multicentre Survey

Background: The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. Objective: This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. Material and Methods: A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. Results: In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20–25 cases according to 8 (61.5%) surgery teams. Conclusions: Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.BACKGROUND The number of robotic-assisted procedures offered in Spain is rapidly increasing despite a lack of consensus criteria for training and credentialling. OBJECTIVE This national multicentre study was designed to analyze the different areas of the robotic urological surgery learning curve. MATERIAL AND METHODS A questionnaire was sent to all 13 urology units in Spain with an active robotics programme requesting information on training and problems encountered. RESULTS In most centres (n = 11, 84.6%), training programmes were animal-based; cadavers were used at only 2 (15.4%). Proctoring in initial procedures was practiced by 12 groups (92.3%). When initiating the robotics programme, the console was shared at 8 units (61.5%). Prior experience in open and/or laparoscopic surgery was reported by 10 of the groups (76.9%), and experience in open surgery only by 2 (15.4%) or robotic surgery alone by 1 (7.7%). The procedure with which the robotics programme was started in all 13 participating units was radical prostatectomy. The number of cases needed to complete the learning curve for this procedure was 20-25 cases according to 8 (61.5%) surgery teams. CONCLUSIONS Up until March 26, 2010, 1,692 operations, mostly radical prostatectomies, were conducted using the da Vinci robot in our country.

Nuevo sling masculino "Argus" para el tratamiento de la incontinencia urinaria de esfuerzo

Resumen es: Objetivos: La incontinencia urinaria masculina de esfuerzo, habitualmente se produce como consecuencia o secuela de una intervencion quirurgica prostatic...

Factores de descompensación miccional y cistocele

Resumen es: Resumen.- OBJETIVOS: Valorar las caracteristicas clinicas y urodinamicas de una serie de mujeres con residuo postmiccional (miccion descompensada) y dife...

Progression of null or mild lower urinary tract symptoms indicative of benign prostatic hyperplasia after 2 years of follow-up in non-treated men aged 40 years or older.

OBJECTIVES After screening men aged 40 years or older for lower urinary tract symptoms (LUTS) indicative of benign prostatic hyperplasia over the years 1999 to 2000, non-treated men with an initial International Prostate Symptoms Score (I-PSS) equal to or lower than 2 were assessed 2 years later for symptom progression. METHODS A cross-sectional study was conducted in 1999 on 1804 men aged 40 years or older who were living in Madrid. In a telephone interview sociodemographic information was requested and LUTS assessed using the I-PSS. Of 975 men with no LUTS or lower than 2 in this baseline survey, 463 were re-interviewed in 2001. The dependent variable was the change from null/mild to moderate/severe LUTS produced over 2 years. RESULTS Over the 2-year period, the mean increase in I-PSS score was 2.20 (95% CI, 1.89-2.51). The cumulative incidence of progression from asymptomatic/mild to moderate/severe disease was 9.94% (95% CI, 7.53-13.00). In the multivariate logistic regression model men who lived in a rural setting (OR, 2.70; P = .01) and armed forces, qualified agriculture and fishing workers (OR, 4.11; P = .05) were independently associated with progression. Age and alcohol intake were also found to interact; intake of 0.01-25.99 g/day in men older than 50 years (OR, 0.28; P = .008) was related to a lower frequency of progression than the same alcohol intake in men younger than 50 years (OR, 2.03; P = .380). CONCLUSIONS After the 2-year period, the incidence of symptom progression was 10% in men aged 40 years or older with an initial I-PSS equal to or lower than 2.